Fundamentals Exam 2 Flashcards
Name the six types of skin dicoloration
Cyanosis Pallor Jaundice Erythema Ecchymosis Petechiae
bluish discoloration typically assessed in nail beds, lips, mouth, conjunctiva
Cyanosis
decrease in tissue oxygenation
absence of underlying red tones in the skin
in brown skinned clients, skin may appear as a yellowish brown tinge
in black skinned clients, skin may appear ashen gray
usually assessed in areas with the least pigmentation:
- conjunctiva - oral mucous membranes - nail beds - palms of hands or soles of feet
Pallor
yellowish orange discoloration typically assessed in sclera, mucous membranes and skin
Jaundice
reddened areas of the skin
Erythema
areas of bruising on the skin
Ecchymosis
pinpoint sized, red or purple spots caused by small hemorrhages in the skin layers
Petechiae
From the RYB color code of tissue.. what does a red, moist tissue mean?
PROTECT/COVER THE TISSUE
Granulation tissue which is progressing toward healing
Skin needs to be protected to avoid disturbing regenerating tissue
In what ways do you protect the skin to help avoid disturbing the regenerating or healing tissue?
Gentle cleansing Protect skin around wound Fill space in wound Cover with appropriate dressing Change as infrequently as possible
From the RYB color code of tissue.. what does yellow tissue mean?
CLEANSE THE TISSUE
There is slough present (stringy substance attached to wound bed – may be accompanied by purulent drainage)
Must be removed before the wound can heal
- Irrigate wound - Apply wet to damp normal saline dressings
From the RYB color code of tissue.. what does black or brown tissue mean?
DEBRIDE THE TISSUE
There is eschar present (Necrotic tissue)
Must be removed before healing can occur – called “Debridement”.
Name the beginning components of a skin assessment
Examine the upper extremities while the client sitting
Remove stockings/stocks to expose the lower extremities
Compare Bilaterally
Examine lesions individually
Use an assessment tool to predict pressure-ulcer risk
Inspect and Palpate Simultaneously
Have Proper Equipment
What are some more specific things to look for when performing a skin assessment?
Temperature (should be warm to touch)
Texture/feel of the skin
Turgor (the skins elasticity.. skin should snap back when pinched and if not then the turgor is poor)
Edema (swelling from excessive fluid in the tissue)
-palpate area – if fingers leave an indentation, it is called pitting edema
Lesions
What are the 4 types of wound drainage?
Serous- clear and watery
Sanguineous- bright red
Serosanguineous- pale, red, and watery
Purulent- thick, yellow, green, tan, or brown
Localized areas of tissue necrosis that develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time
Pressure ulcer
The decrease in blood supply of a pressure ulcer is called..
Ischemia
What is reactive hyperemia?
When pressure on the skin is relieved and turns red from vasodilation because extra blood flow is getting to the area. If redness does not dissappear then there is most likely tissue damage
Describe a stage 1 pressure ulcer
An observable change
Redness
No open skin areas
Describe a stage 2 pressure ulcer
Partial thickness skin loss involving epidermis/dermis
There is now a superficial break in the skin
Abrasion, blister, or a shallow red/pink crater
No slough (which is white and yellow drainage)
Describe a stage 3 pressure ulcer
Full thickness skin loss involving damage or necrosis (death) of subQ tissue
Deep crater
There is no visible bone/tendon/muscle but slough may be present
Describe a stage 4 pressure ulcer
Full thickness skin loss with extensive destruction Tissue necrosis (death of tissue) Damage to muscle, bone, or tendon Slough or eschar (necrotic tissue) may be present
What is an unstageable ulcer?
A suspected deep tissue injury that will look like a bruise but underneath is developing a stage 3 or 4 pressure ulcer
Documented as unstageable, NOT stage 1
What makes an ulcer unstageable?
Full thickness tissue loss where the base is covered by slough (yellow/tan/gray/green/brown) or eschar (tan/brown/black) to the point where the depth nor stage of the wound can be determined until the slough and eschar is removed
Wounds often misclassified as pressure ulcers
Skin Tears Arterial Ulcers Venous Ulcers Diabetic Ulcers Perineal Dermatitis
